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This study investigated first-line managers’ experience of and responses to a concise leadership intervention to facilitate the implementation of oral care clinical practice guidelines (CPGs) in nursing homes. Leadership is known to be an important element in knowledge implementation but little is known as to what supports managers to facilitate the process. By means of a process evaluation with mixed methods, the context and a three-month leadership program was explored, including activities during and in relation to the program, and the effects in terms of oral care CPG implementation plans. While the managers appreciated the intervention and considered improved oral care to be a priority, their implementation plans mainly focused the dissemination of an oral care checklist. The findings suggest that extended implementation interventions engaging both managers and clinical staff are needed, and that a concise intervention does not facilitate first-line managers to adopt behaviors known to facilitate knowledge implementation.

The aim of the present follow-up study was to describe staff perceptions of enabling and inhibitory factors that influenced implementation of evidence-based practice (EBP) for urinary incontinence in a nursing home. Focus group interviews were carried out and the text was deductively analyzed using the PARIHS framework and qualitative content analysis.  Factors believed to be most enabling for implementation were the EBP being considered as relevant and as a social process and visiting the lavatory being considered as a right for all. One determinant of successful implementation was having clear and involved leaders who had a continuous positive attitude toward the EBP and demanded results. Staffs who were given the role of continence agents were important facilitators. The factor believed to inhibit implementation most was staff having to carry out pad-weight tests before prescribing individual incontinence aids. The EBP offers a successful concept for caring for older persons with urinary incontinence in nursing homes. The EBP should be spread, both local and more widely.

OBJECTIVES: We investigated the associations between swallowing dysfunction, poor oral health and mortality among older people in intermediate care in Sweden.

METHODS: This prospective cohort study investigated 391 older people in 36 intermediate care units (clusters). Swallowing function was assessed with the timed water swallow test (TWST), and oral health with the revised oral assessment guide (ROAG) at baseline. Data were collected on age, sex, education level, multimorbidity, cognitive impairment, care dependency and body mass index (BMI). Time to mortality was recorded during the following year. The mixed effects Cox regression model with cluster as a random factor was used to estimate hazards ratios (HR) with 95% confidence intervals (CI).

RESULTS: The median age of the participants was 84 years (interquartile range [IQR]: 11), and 53.3% were females. Mortality within one year was 25.1%. In the adjusted model, swallowing dysfunction and poor oral health were both independently associated with mortality (adjusted HR [aHR]: 1.67, 95% CI 1.02-2.75; P = .041 and aHR: 1.98, 95% CI 1.07-3.65; P = .029, respectively). Participants with combined swallowing dysfunction and poor oral health showed the highest mortality (35.0%) and 2.6 (95% CI 1.15-5.89; P = .022) times higher mortality risk than those with normal swallowing function and good oral health (13.0%).

CONCLUSIONS: Swallowing dysfunction and poor oral health were identified as independent risk factors for mortality in older people in intermediate care. Although further studies are required to verify these findings, they suggest that systematic assessment of swallowing function and oral health status should be performed for care considerations.

BACKGROUND: Extensive studies have shown that older people are negatively impacted by impaired eating and nutrition. The abilities to eat, enjoy food, and participate in social activities associated with meals are important aspects of health-related quality of life (HRQoL) and recovery after illness. This project aims to (i) describe and analyze relationships between oral health and oral HRQoL, swallowing ability, eating ability, and nutritional risk among older individuals admitted to short-term care; (ii) compare the perceptions that older individuals and staff report on care quality related to oral hygiene and eating; and (iii) study the feasibility and effects of a training program for people with impaired swallowing (i.e., dysphagia).

METHODS/DESIGN: This project consists of two parts, which will be performed in five Swedish counties. It will include approximately 400 older individuals and 200 healthcare professionals. Part 1 is a cross-sectional, descriptive study of older people admitted to short-term care. Subjects will be assessed by trained professionals regarding oral health status, oral HRQoL, eating and nutritional risk, and swallowing ability. Swallowing ability will be measured with a teaspoon test and a swallowing capacity test (SCT). Furthermore, subjects and staff will complete a questionnaire regarding their perceptions of care quality. Part 2 is a cluster randomized intervention trial with controls. Older participants with dysphagia (i.e., SCT <10 ml/s, measured in part 1) will be recruited consecutively to either the intervention or control group, depending on where they were admitted for short-term care. At baseline, all subjects will be assessed for oral health status, oral HRQoL, eating and nutritional risk, swallowing ability, and swallowing-related QoL. Then, the intervention group will receive 5 weeks of training with an oral screen for neuromuscular training focused on orofacial and pharyngeal muscles. After completing the intervention, and at six months post-intervention, all assessments will be repeated in both study groups.

DISCUSSION: The results will make important contributions to rehabilitation knowledge, including approaches for improving swallowing function, oral health, and food intake and for improving the quality of oral care for older people.

TRIAL REGISTRATION: This trial was retrospectively registered at ClinicalTrials.gov, on July 4, 2016, identifier: NCT02825927 .

Background: Oral health is important for well-being and overall health. Older peoples oral health is well described in the residential care context, but remains understudied in short-term care.

Objective: The aim of this study was to describe oral health, daily oral care and related factors among older people in short-term care and to compare self-perceived oral health with professional assessment.

Materials and methods: This cross-sectional study included 391 older people in 36 short-term units in 19 Swedish municipalities. Oral health was assessed professionally by clinical oral assessment and the Revised Oral Assessment Guide (ROAG). The older peoples’ perceptions of their own oral health were measured with a global question on self-perceived oral health. Self-care ability was assessed with Katz Index of Activities of Daily Living (Katz-ADL).

Results: Mean age was 82.9 years, 19% of participants were totally edentulous, and 43% had ≥20 teeth. Almost 60% had coating or food debris on their teeth, but only 19% received help with daily oral care. Those who were dependent on help with self-care had around a sixfold higher risk of having oral problems. There was a low level of agreement between the clinical assessment based on ROAG and self-perceived oral health.

Conclusion: Professionals’ assessments of oral health differed considerably from the older peoples own assessments. A higher risk of oral problems and more occurrence of coating or food debris or broken teeth were seen among those dependent on help with self-care (ADL). This study indicates that in order to improve older peoples oral health and oral care we need to provide person-centred oral care and to develop a close collaboration between nursing and dental staff.

OBJECTIVES: It is well known that oral health status is associated with oral health-related quality of life (OHRQoL) in the general population. The aim of this study was to describe and analyze OHRQoL among older people in short-term care and its associated factors.

MATERIALS AND METHODS: This cross-sectional study included 391 older people in 36 short-term care units. Data were collected via clinical oral assessments, questions about self-perceived oral and general health, Katz Index of Activities of Daily Living (Katz-ADL) and the Revised Oral Assessment Guide (ROAG). OHRQoL was measured using the Oral Health Impact Profile (OHIP-14). Multivariate logistic regression models were applied in the analysis.

RESULTS: Poor OHRQoL was reported by 34% of the older people. Associated factors were swallowing problems according to ROAG; quite poor/poor self-perceived physical, psychological, and oral health; and being a woman.

CONCLUSIONS: There is an association between OHRQoL and older people's self-perceived health according to the OHIP-14. This indicates the importance of early detection of oral health problems in frail older people and to assess both oral health and swallowing problems among older people in short-term care.

BACKGROUND: Older people's oral health has improved, and many retain their natural teeth throughout their life. However, their daily oral care can be more difficult because of compromised general health and the reduced capacity for self-care that often comes with old age. More knowledge is needed about how older people view their oral health and oral care. The aim of this study was to describe how older people in short-term care experience their oral health and daily oral care.

METHOD: A descriptive, qualitative study was performed through interviews with 14 older people (74-95 years) recruited from short-term care units in two Swedish regions. Data were analysed using inductive content analysis.

RESULTS: The findings are described in one main category, three categories and nine sub-categories. The main category was Adapting to a changed oral condition while striving to retain independence. The first category, Wanting to manage daily oral care independently, contained three subcategories: Having always brushed my teeth without help, Being satisfied with my mouth and teeth, and Having to accept help if necessary. The second category, Acceptance of changes in oral condition, had three subcategories: Difficulty in chewing and swallowing, Difficulty with tooth brushing, and Not considering a dentist visit to be worth the cost. The third category, Barriers to receiving assistance from staff, had three subcategories: Staff lacking the time to help, Not wanting to be a burden, and Lack of confidence in staff's knowledge.

CONCLUSIONS: The participants were generally satisfied with their oral health despite an expressed need for dental treatment. Daily oral care was something they wanted to manage themselves, and they had a strong desire to stay independent for as long as possible. Closer collaboration between dental and health care staff is necessary in order to implement clinical practice guidelines for oral health care and increase nursing staff's attention towards older peoples' oral health.

OBJECTIVES: To investigate the relationship between malnutrition and potential contributing factors such as poor oral health, dysphagia and mortality among older people in short-term care.

METHODS: This cross-sectional study is a part of the multidisciplinary multicentre project SOFIA (Swallowing function, Oral health and Food Intake in old Age), which includes older people (≥65 years) in 36 short-term care units in five regions of Sweden. Nutritional status was measured with version II of the Minimal Eating Observation and Nutrition Form (MEONF-II), oral health with the Revised Oral Assessment Guide (ROAG), dysphagia with a water swallow test, and the mortality rate was followed for 1 year. Data were analysed using descriptive analysis and logistic regression models to calculate odds ratios for the association between malnutrition and these factors.

RESULTS: Among the 391 participants, the median age was 84 years and 53.3% were women. Mortality rate was 25.1% within 1 year in the total group, and was higher among malnourished participants than among their well-nourished counterparts. Severe dysphagia (OR: 6.51, 95% CI: 2.40-17.68), poor oral health (OR: 5.73, 95% CI: 2.33-14.09) and female gender (OR: 2.2, 95% CI: 1.24-3.93) were independently associated with malnutrition.

CONCLUSION: Mortality rate was higher among malnourished people than those who were well nourished. Severe dysphagia, poor oral health and female gender was predictors of malnutrition among older people in short-term care. These health risks should be given more attention in short-term care with early identification.

Elderly care nurses mostly work alone, without the possibility to share or discuss actual caring and nursing problems with colleagues. They may have access to information such as national guidelines and evidence based methods, but there are no clear routines for how to use this information.

Dalarna University in Sweden has, together with all 15 local authorities in the county of Dalecarlia, developed a knowledge centre for elderly health care. The aim is to support and coordinate work and care development in elderly health care, based on research and evidence based practice. The knowledge centre contributes support regarding processes and structures for knowledge dispersion and practical issues with a special focus on elderly care nurses.

The approach includes registered nurses on several levels working in close collaboration with the Senior Lecturer at the knowledge centre. The nurses indicate relevant nursing problems and participate in the knowledge process and the production of relevant information. If appropriate, the diploma work carried out by nursing students may contribute to the knowledge centre and be a part of the development of care practice.

Since the start of the centre in autumn 2010 work has focused on patient security, implementing national guidelines, routines for delegating health care duties to unqualified staff, i.e., care assistants, introduction- and mentor-programmes for newly employed registered nurses, support networks for nurses with responsibilities in dementia, diabetic care etc. The work has generated a number of ideas for diploma work for nursing students and some ideas for research have also been formulated.

Material produced by the University knowledge centre is available on a Swedish web-site www.du.se/kommunalvardutveckling with free access.

Objectives: Nurses working in elderly health care in the municipalities needs a wide competence. They have to deal with a broad range of health problems, multi-morbidity, medical and nursing treatment, supervision of patients, relatives and staff. The nurses also have to handle with national guidelines (NG) and evidenced based methods (EBM) as well as documenting the care process in data records. The aim of the knowledge centre is to support and coordinate work and care development in elderly health care, based on research and evidence based practice.

Methods: All 15 local authorities in the county of Dalarna and the Dalarna University have developed a Knowledge Centre (KC) for elderly health care. A Senior Lecturer (SL) supervise and develop the work in near collaboration with the nursing staff. The first step was identifying the nurses needs, i.e. support and education, and the identifying process is still going on. The second step was work in small groups under supervision from the (SL). Documents, local care programmes, and working routines from all authorities, together with NG’s and EBM’s, were compiled and developed to updated regional care programmes, in consensus.

Results: So far, the work has contributed to a brief production of documents in nursing care related areas such as patient security, implementing national guidelines, routines for delegating health care duties to unqualified staff, i.e., care assistants, mentor-program for newly employed registered nurses, networks for nurses with responsibilities in dementia, diabetic care etc. The production of documents produced by the knowledge centre is available on a Swedish web-site www.du.se/kommunalvardutveckling with free access. The work has generated a number of ideas for diploma work for nursing students and some ideas for research have also been formulated. The KC has contributed to cooperation between nurses in different authorities.

Conclusions: The KC contributes support regarding processes and structures for knowledge dispersion and practical issues with a special focus on elderly care nurses, and has been successfully implemented.

Knowledge of the course of events and health situation for elderly stroke victims is limited. Most medical complications develop within the first weeks of a stroke, but with reference to shorter hospital stays, it is possible that some problems will not be obvious until after discharge. In total 390 patients >65 years, living in their own homes and having no dementia diagnosis prior to hospital admission, constituted the study population. Interviews with the survivors were performed 1 week after discharge, and 3 and 12 months after hospital admission. Health care records, municipal social service records, and local and national registers were scrutinized. The risk for stroke recurrence or mortality is high during the first period after a stroke incident but the risk decreases during the first six months. Almost all patients (>90%) had a health problem at any time during the year, but few in a specific week, based on patient record data. Differences between health problems reported by patients differed from problems in the health care records. The most frequently interview-reported problems were associated with perception, activity, and tiredness, while the most common record-based findings indicated pain, skin, bladder and bowel function, and breathing and circulation problems. There was co-occurrence between some problems, such as those relating to cognition, activity, and tiredness. This knowledge may be used to identify unvoiced health problems. The utilisation of care, both in hospital and primary health care, and municipality support, was considerably higher the year following the stroke admission, but with an increasing trend the year preceding the admission. With an increasing number of elderly stroke survivors, and increasing needs, this will be a challenge for the municipality and for the relatives

BACKGROUND: A wide range of health problems has been reported in elderly post-stroke patients.

AIM: The aim of this study was to analyse the prevalence and timing of health problems identified by patient interviews and scrutiny of primary health care and municipality elderly health care records during the first post-stroke year.

METHODS: A total of 390 consecutive patients, ≥65 years, discharged alive from hospital after a stroke event, were followed for 1 year post-admission. Information on the health care situation during the first post-stroke year was obtained from primary health care and municipal elderly health care records and through interviews with the stroke survivors, at 1 week after discharge, and 3 and 12 months after hospital admission.

RESULTS: More than 90% had some health problem at some time during the year, while based on patient record data only 4-8% had problems during a given week. The prevalence of interview-based health problems was generally higher than record-based prevalence, and the ranking order was moderately different. The most frequently interview-reported problems were associated with perception, activity, and tiredness, while the most common record-based findings indicated pain, bladder and bowel function, and breathing and circulation problems. There was co-occurrence between some problems, such as those relating to cognition, activity, and tiredness.

CONCLUSIONS: Almost all patients had a health problem during the year, but few occurred in a given week. Cognitive and communication problems were more common in interview data than record data. Co-occurrence may be used to identify subtle health problems.

Aim: There is an essential need to bridge the know-do gap in terms of oral-health-care for frail older people; while there are evidence based guidelines readily available, these guidelines are not altogether implemented in long-term-care (LTC) for older people. Facilitating knowledge translation has been found a complex undertaking, encompassing for example tailoring of evidence in relation to the specific context, considering the barriers and strengths of each setting. While managers and leaders have been found to influence implementation, studies focusing strategies to support the managers have only recently been launched. The aim of this pilot study in Swedish LTC is to support managers in facilitating implementation of evidence-based oral-care guidelines. Methods: Oral-health and knowledge translation experts provided a three month support programme for five managers in four LTC units, including knowledge of national guidelines tailored to LTC, and guidance for the managers on how to collate and execute guideline implementation plans, considering their behaviours, attitudes and actions as leaders in facilitating guideline implementation, underpinned by Gifford’s Model of Leadership. Oral-health measures were collected before and after the intervention, along with managers and staff experience. Results: Although the older people residing in the LTC units mainly had individual care plans for their oral care, and these aligned with the national guidelines, the oral care routines applied varied considerably. The managers were eager to support guideline implementation, and suggested that the intervention programme sustained their ambition. However, unclear roles and urgent everyday issues took its toll, leaving limited opportunities for managers to engage. Conclusions: Implementation of evidence based oral health-care guidelines requires support from primary leaders. Yet, they themselves need to be supported by the context, including top level management as well as staff, and all stakeholders involved in oral care issues need to be engaged.

Background: Lately, oral health-related quality of life (OHRQoL) and nutrition in elderly people living in special accommodations have been placed in focus. It has been shown that dysphagia, malnutrition and poor oral care are frequent in frail elderly people. Swallowing training, using an oral screen, has been successfully tested on stroke-afflicted patients with dysphagia. To what extent dysphagia will have an impact on oral health, and nutrition in elderly is poorly evaluated.  The aims are to study (1) oral health and OHRQoL together with eating, (2) to compare elderly people and nursing staffs’ perceptions of quality of care, and (3) to evaluate the effect of swallowing training on dysphagia. Early detection and intervention of quality of care related to oral hygiene, dysphagia, and eating, may lead to better care and quality of life for the elderly.

Methods:  In this prospective study 400 older people are examined with validated instruments measuring OHRQoL (OHIP14), perception of care quality (QPP), swallowing capacity (SCT) and eating ability (MEONF-II). Patients with dysphagia (n = 40), are included in a swallowing training program (IQoro®), another 40 patients with dysphagia serves as controls.

Results: Preliminary results from 219 patients, (mean age 82 years, 57 % women) shows that 53% are considered to have poor oral hygiene, 75% get no help with oral hygiene, 25% show clinical signs of malnutrition.

Conclusion:Safe eating, swallowing and good oral health for older people is a multidisciplinary responsibility, possible to influence. Key factors of importance for this process will be identified.

Background: Lately, oral health-related quality of life (OHRQoL) and the mealtime situation for elderly people living in special accommodations have been placed in focus. In addition, it has been shown that the prevalence of dysphagia, an important aspect of the eating process, is high among frail elderly people. However, the knowledge on how frail elderly people in general perceive oral health and the mealtime situation is scarce. To our knowledge, there is no research on which eating and oral health related experience, older people regard as important factors in short-term accommodations. A simple and innovative training method for people with dysphagia has been successfully tested among people with stroke. In the present study the aims are (1) to describe OHRQoL, the prevalence of dysphagia and eating difficulties among elderly people in short-term accommodations, as well as their perceptions of care quality related to oral health and eating, (2) to compare elderly peoples’ and nursing staffs’ perceptions of quality, and (3) to evaluate a training program for dysphagia.

Methods and materials: In this prospective study 400 older people will be examined with validated instruments measuring OHRQoL, perception of care quality, swallowing capacity and eating ability (OHIP14, QPP, SCT, MEONF-II). Patients with dysphagia will be included in an intervention program and tested before and after the training period.

Results: Preliminary results will be presented.

Conclusion: Eating and oral health is a multidisciplinary responsibility and key factors of importance for this process will be identified.

Background. The purpose of this study was to analyse whether the parallel life situation between stroke patients and their informal caregivers (dyads) shown in cross-sectional studies prevails also in a longitudinal perspective.

Methods. A total of 377 Swedish stroke patients, aged ‡65 years, and their 268 informal caregivers were followed from hospital admission and one year on. Analyses were based on patient interviews, functional ability (MMSE) score, Nottingham Health Profile (NHP) score, Hospital Anxiety and Depression (HAD) score, self-rated health score, and the Gothenburg Quality of Life (GQL) activity score. Similar information was obtained by postal questionnaires from informal caregivers, also including information on the nature and amount of assistance provided and on Caregiver Burden (CB) score.

Results. Before index admission informal caregivers provided care on average 5 h per week and after discharge 11 h per week (P < 0.0001). Support volume was associated with patient sex (more for men), low patient’s functional ability, low received municipal social service support, closeness of patient–caregiver relation, and short distance to patient’s home. Significant positive associations within the dyads were found for HAD anxiety score (P < 0.0001), total NHP score (P < 0.0001), and GQL activity score (P < 0.0001) after adjustment for patient’s age, sex, functional ability, and patient–caregiver relationship. CB score increased with amount of informal caregiver support, patient’s age, and with low functional ability and low amount of municipal social service support. All these associations were constant across time.

Conclusions. There was an association within the dyads regarding anxiety score, NHP score, and activity score. CB score was generally high.

It has been shown that poor oral health, lack of oral care, dysphagia and malnutrition are common among elderly persons living in special accommodations. All these factors are inter-related and have important impact on quality of life. Aims: The aims of the present study were to (1) describe oral health and oral health related quality of  life (OHRQoL) as well as  the prevalence of dysphagia and eating difficulties among elderly people in short-term accommodations (2) describe perceived care quality related to oral health and eating, (3) evaluate a training program for dysphagia. Methods: In four Swedish counties 320 patients in 30 short-term accommodations were studied by specially trained dental hygienists (RDH), after giving informed consent. Ethical approval has been given. Instruments measuring OHRQoL, oral health, perception of care quality, swallowing capacity and eating ability (OHIP-14, ROAG, QPP, SCT, MEONF-II, SWAL-QoL) were used. Patients with dysphagia were either invited to a 5 weeks training program using an oral screen, IQoro®, or to a control group (40 in each group), comprising follow-up at 5 weeks and 6 months. Results: Data collection is still ongoing for the 6-month follow-up. Preliminary results shows that mean age for the 320 patients was 82 years, 180 women (57%). 294 (91%) were native Swedes and 24 (8%) came from another European country. Physical condition was perceived good or fairly good by 155 (48%) participants, oral health was perceived good or fairly good by 212 (66%), oral hygiene was assessed by RDH as being poor for 156 (49%). 87 (27%) had swollen and bleeding gums, 53 (17%) had red and blistered oral mucosa. 210 (66%) participants perceived that they were given the support they needed at mealtimes but only 68 (22%) received support with daily oral care. Clinical signs of  nutritional risk was identified in 80 (25%) participants and 167 (54%) had a swallowing capacity less than 10 ml/sec. Mean value for OHRQoL measured by OHIP-14 was 7.66, no gender differences were observed. Having dysphagia affected OHRQoL to the worse, p<0.00. Conclusion: There was a discrepancy between participant’s perceptions and the assessments made by RDH, with the latter showing worse results. While being in a state of dependency almost half of the participants perceived their physical condition as good or fairly good and the same applies with regard to oral health. Although half of the study group had poor oral hygiene, the majority managed their oral hygiene by themselves.

Background: Smokers with chronic obstructive pulmonary disease (COPD) have high nicotine dependence making it difficult to quit smoking. Motivational interviewing (MI) is a method that is used in stimulating motivation and behavioral changes.

Objective: To describe smoking cessation communication between patients and registered nurses trained in MI in COPD nurse-led clinics in Swedish primary health care.

Methods: A prospective observational study with structured quantitative content analyses of the communication between six nurses with basic education in MI and 13 patients in non-smoking consultations.

Results: Only to a small extent did nurses’ evoke patients’ reasons for change, stimulate collaboration, and support patients’ autonomy. Nurses provided information, asked closed questions, and made simple reflections. Patients’ communicationwasmainly neutral and focusing on reasons for and against smoking. It was uncommon for patients to be committed and take steps toward smoking cessation.

Conclusion: The nurses did not adhere to the principles of MI in smoking cessation, and the patients focused to a limited extent on how to quit smoking.

Practice implications: To make patients more active, the nurses need more education and continuous training in motivational communication.

Background: There has been insufficient study of the care of persons with diagnosed dementia and the contemporary presence of asthma and/or Chronic Obstructive Pulmonary Disease (COPD). Inhalation treatment requires active patient participation, which is more difficult for a person who has dementia. A consequence of incorrect inhalation technique will be a lack of benefit of medicine affecting dyspnea, fatigue, sleeping problems, cognitive capability and respiratory infections such as pneumonia. Pneumonia is the most common symptom affecting health and well-being among elderly. Improved care and treatment for asthma and COPD may be of importance to these people’s health, quality of life and to community medical costs. The aim is to describe inhalation treatment among persons with dementia who also have asthma and/or COPD. The aim is also to examine the effects of training in inhalation technique and inhalation aids for nursing staff working in dementia care.

Research questions: 

• How is the presence of asthma and/or COPD among persons with dementia related to expected incidence? 
• What inhalation techniques and levels of inhalation strength occur among patients with asthma, COPD and dementia? 
• How is the quality of life for persons with dementia and asthma and/or COPD influenced by whether the nursing staff is given training in inhalation technique, inhalation aids and devices?

Method: The project will be planned in two parts: firstly, a descriptive epidemiological mapping, scrutinizing register and journal data of the diagnoses asthma and COPD among persons with dementia: secondly, an observation of inhalation techniques and a control of inhalation strength among patients in dementia care with asthma and/or COPD. This will be carried out before and after a randomized controlled training intervention in inhalation technique and inhalation aids given to nursing staff in dementia care.